What Is Toxic Shock Syndrome?

  • Raadhika Agrawal Bachelor of Medicine and Bachelor of Surgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
  • Sophie Downton BSc, Biomedical Sciences, University of Reading, UK

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Toxic shock syndrome (TSS) is a rare but potentially life-threatening illness that is characterised by the sudden onset of high fever, rash, and low blood pressure, which can lead to multiple organ failure and lethal shock.1,2 It is caused by different species of bacteria called Staphylococcus aureus or Streptococcus pyogenes, which release toxic bacterial superantigens (SAGS) into the body.

It is important to understand the clinical presentation and warning signals of TSS because there is a common misconception that TSS only affects menstruating individuals through the use of tampons. Although menstruating women are more prone to gaining this infection,3 it affects both women and men equally.

Causes and bacterial origin of TSS

Staphylococcus aureus (Staph) and group A streptococci, such as Streptococcus pyogenes (Strep), have been identified as the culprits of this disease. Under normal circumstances, these bacteria are harmless because they live on your skin or in your throat and mouth. However, complications arise when these bacteria grow rapidly, gain entry into your body, and release toxins in your bloodstream.


Staphylococcus is an extremely common bacteria; ¼ of the population's skin is colonised by it.4 It is a normal component of the skin flora (a complex ecosystem of different bacterial species), though disease onset is more likely if Staphylococcus dominates the skin flora, as breaks in the skin barrier are a common route for infection. Factors that affect Staphylococcal growth rate are pH, humidity, and sweat.

Staph produces five major toxins, where two are linked to the development of TSS: TSST-1 and enterotoxins.5 TSST-1 is a superantigen produced at the site of infection in the bloodstream, which binds to receptors on immune cells. This binding can stimulate an inflammatory response, which can be fatal for the patient through the causation of physiological changes such as fever spikes, rashes, low blood pressure, and poor end-organ perfusion (reduced oxygen delivery to organs) that can lead to death. Enterotoxins are stable toxins that can remain active even after the bacteria that produced these toxins are killed; if enterotoxins enter the bloodstream, they can cause TSS.


Streptococcus is another common type of bacteria and is most commonly associated with mild, self-resolving infections of the skin.6 It uses enzymes and toxins that contribute to its virulence, such as streptolysin O, which destroys the outer cell membranes of vital cells like red blood cells. Streptococcus also secretes erythrogenic (red blood cell-killing) exotoxins that produce similar responses to TSST-1; these toxins bind to immune cells, leading to the release of inflammatory molecules called cytokines and causing TSS7.

Who is at risk of TSS?

TSS can affect anyone, regardless of gender or age. The following things can increase the risk of developing TSS:

  1. Tampon use:

When using tampons or other internal period products, the risk of developing TSS increases. Internal period products, when not changed frequently, can lead to a buildup of harmful bacteria in the vaginal canal. From here, there is a chance of bacteria entering the bloodstream through small abrasions from the insertion of period products.8

  1. Use of menstrual cups or other intrauterine devices:

Healthcare professionals also believe that menstrual cups, diaphragms, or cervical caps that stay in your vagina for longer than the recommended time can increase your risk of getting TSS.

  1. Skin Wounds and Burns:

Bacteria can gain entry into your body through openings in the skin.

  1. Childbirth: including vaginal birth and caesarean section

A few cases of the syndrome have been reported in individuals who have recently given birth, as skin wounds are prevalent in childbirth.2

  1. Immune System Weakness
  2. Prior History of TSS 

Symptoms of TSS

The most common symptoms of TSS are similar to many other types of illnesses.

These include:2

  • High Fever
  • Rash
  • Sudden Low Blood Pressure
  • Muscle Aches
  • Vomiting and Diarrhoea
  • Redness of Eyes, Mouth, and Throat

You should see your doctor immediately if you display these symptoms, especially if you've recently used tampons or if you have a skin or wound infection, as these can increase your risk of getting TSS.

Diagnosis of TSS

Firstly, you will have a chat with your healthcare provider to assess your symptoms. From there, you’ll be asked to provide blood or urine samples to test for the presence of either Staphylococcal or Streptococcal bacteria. You may then get your throat, cervix, or vagina swabbed, and samples will be sent over to the labs to identify the bacterial culture.

Treatment for TSS

If you develop TSS, you’ll likely be hospitalised, where you’ll be treated with intravenous antibiotics, usually penicillin. You will also receive supportive care to treat other symptoms associated with TSS; for example, receiving medication to help control your blood pressure and treating dehydration through an IV drip.

In extreme cases, surgery may be necessary to remove infections from cuts and wounds or to drain infected areas of the body.

Reducing the risk of acquiring TSS

TSS is rare, but here are some ways to reduce the likelihood of developing TSS:

  1. Proper Tampon Use:

Doctors recommend changing tampons every 4 – 8 hours to prevent an infection.8 Only open packaging when needed to further prevent contamination between the tampon and your vagina, and wash your hands before and after tampon insertion.

  1. Choosing Lower Absorbency Tampons:

Lowering the absorbency of tampons can reduce the chance of developing TSS, as it promotes more frequent tampon change.

  1. Alternatives to Tampons:

Tampon-related TSS can be reduced when alternating between tampons and pads from time to time.8

  1. Hand Hygiene:

Regularly washing hands is the most effective way to prevent the spread of germs. Keeping on top of hand hygiene will reduce the chance of getting not only TSS but other diseases as well.

  1. Wound Care and Sterilisation:

Treat wounds and burns as soon as possible, with clean hands and first aid. If there are signs of infection, such as swelling, redness, or oozing of pus, contact your healthcare professional.

  1. Awareness of Symptoms:

Understand the symptoms of TSS and get immediate medical help if you are worried you may have it.


Toxic shock syndrome is a rare illness caused by bacterial infection of the bloodstream that can lead to high fever, low pressure, and organ damage if not treated quickly. The chances of getting TSS is 1 in every 100,000 people.9 Staying aware of the symptoms of TSS and following preventative measures as outlined above reduces the likelihood of developing TSS. Although, if you are still concerned about your health, contact your GP or pharmacist for more information.


  1. McCormick JK, Yarwood JM, Schlievert PM. Toxic Shock Syndrome and Bacterial Superantigens: An Update. Annual Review of Microbiology. 2001 Oct;55(1):77–104.
  2. NHS Choices. Toxic shock syndrome [Internet]. NHS. 2019. Available from: https://www.nhs.uk/conditions/toxic-shock-syndrome/
  3. Parsonnet J, Hansmann MA, Delaney ML, Modern PA, DuBois AM, Wieland-Alter W, et al. Prevalence of Toxic Shock Syndrome Toxin 1-Producing Staphylococcus aureus and the Presence of Antibodies to This Superantigen in Menstruating Women. Journal of Clinical Microbiology [Internet]. 2005 Sep [cited 2022 Apr 26];43(9):4628–34. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1234102/
  4. Osmosis from Elsevier. Staphylococcus aureus [Internet]. www.youtube.com. 2020 [cited 2023 Oct 13]. Available from: https://www.youtube.com/watch?v=wdo3E2w0cI8&t=777s
  5. Dinges MM, Orwin PM, Schlievert PM. Exotoxins of Staphylococcus aureus. Clinical Microbiology Reviews [Internet]. 2000 Jan 1;13(1):16–34. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC88931/
  6. Reglinski M, Sriskandan S. Streptococcus pyogenes. Molecular Medical Microbiology [Internet]. 2015;2:675–716. Available from: https://www.sciencedirect.com/science/article/pii/B978012397169200038X
  7. Shannon BA, McCormick JK, Schlievert PM. Toxins and Superantigens of Group A Streptococci. Microbiology Spectrum. 2019 Jan 11;7(1).
  8. Toxic Shock Syndrome (TSS): causes, symptoms and treatment [Internet]. tampax.co.uk. [cited 2023 Oct 13]. Available from: https://tampax.co.uk/en-gb/period-health/toxic-shock-syndrome-causes-treatment/#reducing-the-risk-of-toxic-shock-syndrome
  9. Ross A, Shoff HW. Toxic Shock Syndrome [Internet]. Nih.gov. StatPearls Publishing; 2019. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459345/

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Bachelors of Science – BSc Biological Sciences, University of Reading

Lavinia is a recent graduate who is delving into the world of medical writing.

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